Réanimation cardio-pulmonaire et travail en équipe : réflexion autour du concept aéronautique de "Crew Resource Management"

La prise en charge intra-hospitalière des arrêts cardio-respiratoires s'appuie sur une application précoce des gestes de base de la réanimation cardio- pulmonaire (massage cardiaque, ventilation pulmonaire, défibrillation) par les soignants. À l'heure actuelle, les formations à la réanimation cardio-pulmonaire impliquent uniquement l'apprentissage de gestes techniques et de connaissances théoriques, mais omettent totalement les aspects relationnels, ainsi que les problèmes de communication et de travail en équipe. Au travers d'une revue critique de la littérature médicale et aéronautique, nous proposons une nouvelle piste de formation dans le domaine de la réanimation cardio-pulmonaire. En s'appuyant sur les travaux réalisés dans l'aviation, dans les domaines de l'erreur humaine et du travail en équipe, nous offrons finalement une adaptation du "Crew Resource Management" ainsi qu'une série de recommandations, visant à intégrer les éléments relationnels et le facteur humain dans les cours de réanimations cardio-pulmonaires.

Artificial Urinary Sphincter based on smart materials

Objective: There are only a few established artificial urinary sphincters for treatment of incontinence. We have developed a new device composed by three parts: the actuator, three contractile rings and a control unit. The actuator is made of Nitinol fibers, driven by microprocessor. The fibers are linked to the rings placed around the urethra. They function with alternance in their open and closed position. This concept is called piano concept. With this set-up, the constant compression on the urethra is strongly reduced. Methods: Six male sheep have been used for this study. The sphincter was open each hour for a period of 10 min., to guaranty urination. The bladder was filled with water while one cuff was closed and bladder pressure was monitored. The animals were sacrificed. Two biopsies around two cuffs of each explant and all three cuffs from each explant including urethra were analyzed. Urethra not surrounded by a cuff was taken as control. Results: The pressure exerted by the sphincter around the urethra provided continence. Simulated incontinence occurred at a pressure of 1bar measured on the bladder wall using a pressure probe. The closing force of the cuff was approx. 0·7N. No difference in tissue structure and organization of the urethra with and without artificial sphincter was observed. Conclusions: This device has several advantages compared to other urinary sphincters. It is easy to implant, has no hydraulic nature and reduces ischemic injury of the urethra by the alternance of urethral part compressed. Proof of concept in vivo has been demonstrated. Other studies are planned to determine long-term outcome.

Impact of biological and environmental variabilities on biological monitoring: an approach using toxicokinetic models

Biological monitoring of occupational exposure is characterized by important variability, due both to variability in the environment and to biological differences between workers. A quantitative description and understanding of this variability is important for a dependable application of biological monitoring. This work describes this variability,using a toxicokinetic model, for a large range of chemicals for which reference biological reference values exist. A toxicokinetic compartmental model describing both the parent compound and its metabolites was used. For each chemical, compartments were given physiological meaning. Models were elaborated based on physiological, physicochemical, and biochemical data when available, and on half-lives and central compartment concentrations when not available. Fourteen chemicals were studied (arsenic, cadmium, carbon monoxide, chromium, cobalt, ethylbenzene, ethyleneglycol monomethylether, fluorides, lead, mercury, methyl isobutyl ketone, penthachlorophenol, phenol, and toluene), representing 20 biological indicators. Occupational exposures were simulated using Monte Carlo techniques with realistic distributions of both individual physiological parameters and exposure conditions. Resulting biological indicator levels were then analyzed to identify the contribution of environmental and biological variability to total variability. Comparison of predicted biological indicator levels with biological exposure limits showed a high correlation with the model for 19 out of 20 indicators. Variability associated with changes in exposure levels (GSD of 1.5 and 2.0) is shown to be mainly influenced by the kinetics of the biological indicator. Thus, with regard to variability, we can conclude that, for the 14 chemicals modeled, biological monitoring would be preferable to air monitoring. For short half-lives (less than 7 hr), this is very similar to the environmental variability. However, for longer half-lives, estimated variability decreased. [Supplementary materials are available for this article. Go to the publisher's online edition of Journal of Occupational and Environmental Hygiene for the following free supplemental resource: tables detailing the CBTK models for all 14 chemicals and the symbol nomenclature that was used.] [Authors]

Lateral condyle fracture of the humerus in children treated with bioabsorbable materials

Les fractures du condyle externe de l'enfant sont un traumatisme relativement fréquent qui survient le plus souvent chez l'enfant entre 5 et 15 ans. Elles sont classées en 3 grades : le grade 1 sans déplacement qui peuvent être traitées conservativement et les grades 2 (déplacées) et 3 (disloquées) qui nécessitent une prise en charge chirurgicale par réduction ouverte et embrochage. Le traitement traditionnel de ces fractures consistent en la mise en place de broches/vis métalliques qui doivent être retirées quelques semaines plus tard lors d'une seconde intervention. Depuis les années 90, des matériaux bio-résorbables à base d'acide polyglycoliques sont apparus en chirurgie orthopédique et traumatologique. En raison de la survenue de complications telles que réactions inflammatoires, formation de séromes ou ostéolyse, l'utilisation du matériel conventionnel a été préférée. Cependant, depuis quelques années, de nouveaux matériaux en acide polylactique sont apparus sur le marché. La période de résorption étant beaucoup plus lente, ces matériaux induisent des réactions beaucoup plus faibles, sans conséquences cliniques relevées jusqu'à présent. Chez l'adulte, de récentes études ont prouvés l'efficacité et l'absence d'effets secondaires liés à ces matériaux. Par contre, chez l'enfant, peu d'études à moyen terme ont été réalisées et l'impact sur l'os en croissance est peu connu, même si pour l'heure aucune conséquence clinique n'a été relevée. Dans le cadre de notre étude, nous avons comparé 2 groupes d'enfants traités pour des fractures du condyle externe du coude. Le premier groupe traité par du matériel conventionnel et le second par matériel résorbable. Les enfants ont tous étés suivis de manière très étroite durant la première année et la récupération clinique est similaire pour les 2 groupes. A 4 ans du traumatisme, les résultats fonctionnels sont identiques pour les 2 groupes et aucune complication liée au matériel résorbable n'a été mise en évidence. Par ailleurs, à 1 et 4 ans, les clichés radiologiques montrent l'absence de lésions liées au matériel résorbable. En conclusion, dans le cadre de notre travail nous avons pu montrer l'efficacité des matériaux résorbables dans la prise en charge des fractures du condyle externe du coude chez l'enfant. Ces matériaux permettent d'optimiser la prise en charge de ce type de fracture en prévenant un risque opératoire et anesthésique liés à une seconde intervention nécessaire au retrait du matériel d'ostéosynthèse conventionnel. Par ailleurs le coût lié à la prise en charge globale de ce type de fracture est moindre lors de l'utilisation de matériel résorbable.

Atrial assist device, a new alternative to lifelong anticoagulation?

OBJECTIVE: Atrial fibrillation is a very common heart arrhythmia, associated with a five-fold increase in the risk of embolic strokes. Treatment strategies encompass palliative drugs or surgical procedures all of which can restore sinus rhythm. Unfortunately, atria often fail to recover their mechanical function and patients therefore require lifelong anticoagulation therapy. A motorless volume displacing device (Atripump) based on artificial muscle technology, positioned on the external surface of atrium could avoid the need of oral anticoagulation and its haemorrhagic complications. An animal study was conducted in order to assess the haemodynamic effects that such a pump could provide. METHODS: Atripump is a dome-shape siliconecoated nitinol actuator sewn on the external surface of the atrium. It is driven by a pacemaker-like control unit. Five non-anticoagulated sheep were selected for this experiment. The right atrium was surgically exposed, the device sutured and connected. Haemodynamic parameters and intracardiac ultrasound (ICUS) data were recorded in each animal and under three conditions; baseline; atrial fibrillation (AF); atripump assisted AF (aaAF). RESULTS: In two animals, after 20 min of AF, small thrombi appeared in the right atrial appendix and were washed out once the pump was turned on. Assistance also enhanced atrial ejection fraction. 31% baseline; 5% during AF; 20% under aaAF. Right atrial systolic surfaces (cm2) were; 5.2 +/- 0.3 baseline; 6.2 +/- 0.1 AF; 5.4 +/- 0.3 aaAF. CONCLUSION: This compact and reliable pump seems to restore the atrial "kick" and prevents embolic events. It could avoid long-term anticoagulation therapy and open new hopes in the care of end-stage heart failure.

Biofilm formation on bone grafts and bone graft substitutes: comparison of different materials by a standard in vitro test and microcalorimetry.

We analyzed the initial adhesion and biofilm formation of Staphylococcus aureus (ATCC 29213) and S. epidermidis RP62A (ATCC 35984) on various bone grafts and bone graft substitutes under standardized in vitro conditions. In parallel, microcalorimetry was evaluated as a real-time microbiological assay in the investigation of biofilm formation and material science research. The materials beta-tricalcium phosphate (beta-TCP), processed human spongiosa (Tutoplast) and poly(methyl methacrylate) (PMMA) were investigated and compared with polyethylene (PE). Bacterial counts (log(10) cfu per sample) were highest on beta-TCP (S. aureus 7.67 +/- 0.17; S. epidermidis 8.14 +/- 0.05) while bacterial density (log(10) cfu per surface) was highest on PMMA (S. aureus 6.12 +/- 0.2, S. epidermidis 7.65 +/- 0.13). Detection time for S. aureus biofilms was shorter for the porous materials (beta-TCP and processed human spongiosa, p < 0.001) compared to the smooth materials (PMMA and PE), with no differences between beta-TCP and processed human spongiosa (p > 0.05) or PMMA and PE (p > 0.05). In contrast, for S. epidermidis biofilms the detection time was different (p < 0.001) between all materials except between processed human spongiosa and PE (p > 0.05). The quantitative analysis by quantitative culture after washing and sonication of the material demonstrated the importance of monitoring factors like specific surface or porosity of the test materials. Isothermal microcalorimetry proved to be a suitable tool for an accurate, non-invasive and real-time microbiological assay, allowing the detection of bacterial biomass without removing the biofilm from the surface.

Properties of debris flow deposits and source materials compared: implications for debris flow characterization

In the Alps, debris flow deposits generally contain < 5% clay-size particles, and the role of the surface-charged < 2 mu m particles is often neglected, although these particles may have a significant impact on the rheological properties of the interstitial fluid. The objective of this study was to compare debris flow deposits and parent materials from two neighbouring catchments of the Swiss Alps, with special emphasis on the colloidal constituents. The catchments are small in area (4 km(2)), 2.5 km long, similar in morphology, but different in geology. The average slopes are 35-40%. The catchments were monitored for debris flow events and mapped for surface aspect and erosion activity. Debris flow deposits and parent materials were sampled, the clay and silt fractions extracted and the bulk density, < 2 mm fraction bulk density, particle size distribution, chemical composition, cation exchange capacity (CEC) and mineralogy analysed. The results show that the deposits are similar to the parent screes in terms of chemical composition, but differ in terms of: (i) particle size distribution; and (ii) mineralogy, reactivity and density of the < 2 mm fraction. In this fraction, compared with the parent materials the deposits show dense materials enriched in coarse monocrystalline particles, of which the smallest and more reactive particles were leached. The results suggest that deposit samples should not be considered as representative of source or flow materials, particularly with respect to their physical properties.

Round robin test: wear of nine dental restorative materials in six different wear simulators - supplement to the round robin test of 2005.

OBJECTIVE: The purpose of the present study was to submit the same materials that were tested in the round robin wear test of 2002/2003 to the Alabama wear method. METHODS: Nine restorative materials, seven composites (belleGlass, Chromasit, Estenia, Heliomolar, SureFil, Targis, Tetric Ceram) an amalgam (Amalcap) and a ceramic (IPS Empress) have been submitted to the Alabama wear method for localized and generalized wear. The test centre did not know which brand they were testing. Both volumetric and vertical loss had been determined with an optical sensor. After completion of the wear test, the raw data were sent to IVOCLAR for further analysis. The statistical analysis of the data included logarithmic transformation of the data, the calculation of relative ranks of each material within each test centre, measures of agreement between methods, the discrimination power and coefficient of variation of each method as well as measures of the consistency and global performance for each material. RESULTS: Relative ranks of the materials varied tremendously between the test centres. When all materials were taken into account and the test methods compared with each other, only ACTA agreed reasonably well with two other methods, i.e. OHSU and ZURICH. On the other hand, MUNICH did not agree with the other methods at all. The ZURICH method showed the lowest discrimination power, ACTA, IVOCLAR and ALABAMA localized the highest. Material-wise, the best global performance was achieved by the leucite reinforced ceramic material Empress, which was clearly ahead of belleGlass, SureFil and Estenia. In contrast, Heliomolar, Tetric Ceram and especially Chromasit demonstrated a poor global performance. The best consistency was achieved by SureFil, Tetric Ceram and Chromasit, whereas the consistency of Amalcap and Heliomolar was poor. When comparing the laboratory data with clinical data, a significant agreement was found for the IVOCLAR and ALABAMA generalized wear method. SIGNIFICANCE: As the different wear simulator settings measure different wear mechanisms, it seems reasonable to combine at least two different wear settings to assess the wear resistance of a new material.

Association of genetic variation with systolic and diastolic blood pressure among African Americans: the Candidate Gene Association Resource study.

The prevalence of hypertension in African Americans (AAs) is higher than in other US groups; yet, few have performed genome-wide association studies (GWASs) in AA. Among people of European descent, GWASs have identified genetic variants at 13 loci that are associated with blood pressure. It is unknown if these variants confer susceptibility in people of African ancestry. Here, we examined genome-wide and candidate gene associations with systolic blood pressure (SBP) and diastolic blood pressure (DBP) using the Candidate Gene Association Resource (CARe) consortium consisting of 8591 AAs. Genotypes included genome-wide single-nucleotide polymorphism (SNP) data utilizing the Affymetrix 6.0 array with imputation to 2.5 million HapMap SNPs and candidate gene SNP data utilizing a 50K cardiovascular gene-centric array (ITMAT-Broad-CARe [IBC] array). For Affymetrix data, the strongest signal for DBP was rs10474346 (P= 3.6 × 10(-8)) located near GPR98 and ARRDC3. For SBP, the strongest signal was rs2258119 in C21orf91 (P= 4.7 × 10(-8)). The top IBC association for SBP was rs2012318 (P= 6.4 × 10(-6)) near SLC25A42 and for DBP was rs2523586 (P= 1.3 × 10(-6)) near HLA-B. None of the top variants replicated in additional AA (n = 11 882) or European-American (n = 69 899) cohorts. We replicated previously reported European-American blood pressure SNPs in our AA samples (SH2B3, P= 0.009; TBX3-TBX5, P= 0.03; and CSK-ULK3, P= 0.0004). These genetic loci represent the best evidence of genetic influences on SBP and DBP in AAs to date. More broadly, this work supports that notion that blood pressure among AAs is a trait with genetic underpinnings but also with significant complexity.

Artificial muscle: the human chimera is the future.

Severe heart failure and cerebral stroke are broadly associated with the impairment of muscular function that conventional treatments struggle to restore. New technologies enable the construction of "smart" materials that could be of great help in treating diseases where the main problem is muscle weakness. These materials "behave" similarly to biological systems, because the material directly converts energy, for example electrical energy into movement. The extension and contraction occur silently like in natural muscles. The real challenge is to transfer this amazing technology into devices that restore or replace the mechanical function of failing muscle. Cardiac assist devices based on artificial muscle technology could envelope a weak heart and temporarily improve its systolic function, or, if placed on top of the atrium, restore the atrial kick in chronic atrial fibrillation. Artificial sphincters could be used to treat urinary incontinence after prostatectomy or faecal incontinence associated with stomas. Artificial muscles can restore the ability of patients with facial paralysis due to stroke or nerve injury to blink. Smart materials could be used to construct an artificial oesophagus including peristaltic movement and lower oesophageal sphincter function to replace the diseased oesophagus thereby avoiding the need for laparotomy to mobilise stomach or intestine. In conclusion, in the near future, smart devices will integrate with the human body to fill functional gaps due to organ failure, and so create a human chimera.

Importance of a three-dimensional measure of humeral head subluxation in osteoarthritic shoulders.

HYPOTHESIS: During total shoulder arthroplasty (TSA), humeral head subluxation may be difficult to manage. Furthermore, there is a risk for postoperative recurrence of subluxation, affecting the outcome of TSA. An accurate evaluation of the subluxation is necessary to evaluate this risk. Currently, subluxation is measured in 2 dimensions (2D), usually relative to the glenoid face. The goal of this study was to extend this measure to 3 dimensions (3D) to compare glenohumeral and scapulohumeral subluxation and to evaluate the association of subluxation with the glenoid version. MATERIALS AND METHODS: The study analyzed 112 computed tomography scans of osteoarthritic shoulders. We extended the usual 2D definition of glenohumeral subluxation, scapulohumeral subluxation, and glenoid version by measuring their orientation in 3D relative to the scapular plane and the scapular axis. We evaluated statistical associations between subluxation and version in 2D and 3D. RESULTS: Orientation of subluxation and version covered all sectors of the glenoid surface. Scapulohumeral subluxation and glenoid version were highly correlated in amplitude (R(2) = 0.71; P < .01) and in orientation (R(2) = 0.86; P < .01). Approximately every degree of glenoid version induced 1% of scapulohumeral subluxation in the same orientation of the version. Conversely, glenohumeral subluxation was not correlated to glenoid version in 2D or in 3D. CONCLUSIONS: Orientation of the humeral subluxation is rarely within the arbitrary computed tomography plane and should therefore be measured in 3D to detect out-of-plane subluxation. Scapulohumeral subluxation and glenoid version measured in 3D could bring valuable information for decision making during TSA.